neurosurgery

UConn Health this winter established New England’s first Cranial Nerve and Brainstem Disorder Program, bringing together a multidisciplinary team of experts to streamline care for patients with such conditions.

Led by esteemed neurosurgeon Dr. Ketan R. Bulsara and ear, nose, and throat specialist Dr. Daniel Roberts, the team collaborates with specialists from nearly a dozen departments and will encompass clinical care, research, and teaching.

“One of the core principles of patient care at UConn Health is a multidisciplinary approach to providing personalized care to optimize patient outcomes,” Bulsara says. “The Cranial Nerve and Brainstem Disorder Program extends that core principle by bringing together world-renowned experts in their fields. We are fortunate at UConn Health to have such an accomplished team across so many different specialties that is willing to work together to provide the best care for our patients.”

The program guarantees rapid evaluation of patients, regardless of whether they were diagnosed recently or long ago. Patients or practitioners can submit a request through the center referral portal, which is staffed by Bulsara and Roberts. For neurosurgical or ear, nose, and throat issues, the patient will be offered an initial evaluation appointment that is within a week of their request.

If the cranial nerve or brainstem issue is not related to the ear, nose, and throat or a neurosurgical issue, the physicians will connect the patient with the appropriate service.

“To have patients be able to access care in a very timely and expedited fashion is key,” Roberts says. “A patient can call us and we’ll say, ‘We’ll see you within a week’ to get the ball rolling and help direct them through this complicated process.”

Dr. Ketan Bulsara and Dr. Daniel Roberts use the new augmented reality microscope in the hybrid OR at UConn John Dempsey Hospital.

UConn Health is the first hospital in the nation to acquire a high-tech surgical microscope with augmented reality capabilities to visually assist surgeons during complex neurological and spinal surgeries. This technology — the latest added to UConn Health’s state-of-the-art hybrid operating room — provides surgeons with an enhanced 3D visualization of the surgical field at the highest magnification possible. It can also illuminate the blood flow through various brain tissues, making more precise surgical interventions possible.

“The advanced augmented reality, image-guided microscope allows us to go beyond what we can normally see with our naked eye and traditional microscopes. It allows practitioners from multiple surgical specialties to treat even more complex lesions more safely,” says Dr. Ketan Bulsara, chief of the Division of Neurosurgery at UConn Health.

The microscope’s unique FusionOptics technology allows a surgeon to see greater anatomical detail with increased sharpness, such as the tiny distances between the smallest blood vessels and nerve structures, without needing to refocus the microscope. It also has the ability to brightly light up tiny blood vessels in the brain to distinguish them from other surrounding brain tissue, helping surgeons navigate the complex and delicate surgical field.

The microscope also includes a video camera that allows surgeons to choose one of three enhanced overlays to amplify the view of the surgical field. The three views are a real-time, highly magnified naked anatomy; a black-and-white, fluorescence-enhanced view to see greater tissue dimensions and blood flow; and a brightly colored, fluorescence-enhanced view of naturally colored anatomy to see the intricate blood flow and tissue outlines during a microsurgical procedure.

The ARveo Augmented Reality microscope is made by Leica Microsystems, a developer and manufacturer of microscopes and scientific instruments for the analysis of microstructures and nanostructures.

This spring, neurosurgery chief Dr. Ketan Bulsara and his team were the first to perform surgery in UConn John Dempsey Hospital’s 1,200-square-foot hybrid operating room.

The team leveraged the new high-tech room and its dual advanced X-ray imaging capabilities to guide a successful minimally invasive neurological procedure.

“There are not many biplane hybrid operating rooms in the United States, and there are only a handful along the East Coast,” says Bulsara. “The biplane imaging provides surgeons multiple views and not only makes patient care safer but also allows surgeons to do things that we could not ordinarily do inside the operating room.”

The hybrid room gives surgeons the ability to perform a range of procedures in one setting, from minimally invasive treatments to the most complex neurosurgery, interventional cardiology, and vascular procedures.

“The hybrid operating room allows surgeons to choose what they feel is the best treatment for that patient,” says Bulsara.

According to Bulsara, the hybrid room enables UConn Health to continue providing world-class care to its patients while shaping the future of surgery and medicine and optimizing the personalized care given to each individual patient.

The hybrid operating room is a new tool for us that allows us to deliver health care in ways we have never been able to before.

“The hybrid operating room enables us to deliver health care in ways we have never been able to before,” says Lahey. “We now have all the advanced radiological equipment inside a huge operating room.”

All the high-tech equipment in the hybrid OR hangs from the ceiling, including imaging equipment, large plasma screens, and LED boom lights that assist surgeons with brighter and sharper lighting of the surgical field. A high-resolution video system provides real-time video and photo imaging during surgery for direct communication with the Department of Pathology or teleconferencing and live broadcasts of surgery for physician training and medical education.

Dr. Charan K. Singh, right, threads a catheter through a 3-D printed model of arteries in the brain while speaking with Dr. Clifford Yang, one of the model’s creators, at UConn Health. Peter Morenus

The first time a young surgeon threads a wire through a stroke victim’s chest, up through the neck, and fishes a blood clot out of the brain may be one of the most harrowing moments in their career. Now, a UConn Health radiologist and a medical physicist have made it easier for them to get some practice first. The team made a life-size model of the arteries that wire must pass through, using brain scans and a 3-D printer. They will make the pattern freely available to any doctor who requests it.

Five years ago, the Food and Drug Administration (FDA) approved mechanical thrombectomy — using a wire to pull clots out of the brains of stroke victims. A trap at the end of the wire opens like a little snare that captures the clot, which is then dragged out of the patient.

After a couple months of tweaking, a UConn Health radiologist and a medical physicist found they could print a true-to-life teaching model of the brain’s major arteries for about $14.

A lot can go wrong on that journey. One of the most dangerous complications is also one of the most likely: another clot can be accidentally knocked loose from the walls of the arteries and get stuck in the heart, the lungs, or elsewhere in the brain. Computer simulations of the procedure exist, but they are prohibitively expensive for many medical schools to purchase. Yet interventional radiologists and neurosurgeons need to train extensively before they work on a real person.

UConn Health cardiac radiologist Dr. Clifford Yang and medical physicist intern David Brotman knew they could help young doctors feel more comfortable with the mechanics.

Because of the prohibitive costs of computer simulation programs, often the first time a surgeon threads a wire into a stroke victim’s brain to remove a blood clot is during the doctor’s first surgery. Using brain scans and a 3-D printer, a UConn team made a life-size model of the arteries surgeons must navigate during the procedure so they can practice first. The pattern is available for free to any doctor who requests it.

“What matters is the ability of the doctor to be confident in guiding the wire,” says Brotman. He and Yang found a brain scan of a patient with typical blood vessel structure and used the scan to design a 3-D model of the blood vessels. Finding a good scan was easy: UConn has an immense library of scans from computed tomography (CT) and magnetic resonance imaging (MRI) of patients. The tough part was converting the data into something a 3-D printer could interpret. Brotman and Yang found and modified publicly available software to do that, and after a couple months of tweaking, they found they could print a true-to-life teaching model of the brain’s major arteries for about $14.

Technically called a brain perfusion phantom, the model is surprisingly delicate. Holding it in your hand brings home just how small the arteries are, even in an adult man. The top arch of the aorta in the chest, big enough to slide an adult’s pinky finger through, connects to the carotid in the neck and then on to the Circle of Willis in the brain, which is no thicker than a fat piece of yarn. The circle has six branches. Each branch supplies blood to one-sixth of the brain. It is in these branches that clots are most likely to get stuck and cause serious damage.

“We are using this model to teach students,” says UConn interventional radiologist Dr. Charan Singh. “Obviously, it won’t feel like the human body. But it will improve their knowledge of anatomy and give them basic technique on how to move the catheter.”

What matters is the ability of the doctor to be confident in guiding the wire.

— UConn Health medical physicist intern David Brotman, one of the model’s creators

Singh demonstrates how a slight twist can violently flip the catheter, which is dangerous. It could knock off new clots into the bloodstream. The model isn’t perfect — there are several different ways a person’s aorta can be shaped, and the other veins can vary too. But students can get good practice with it, Singh says.

Dr. Ketan Bulsara, UConn’s chief of neurosurgery, also likes the technology. He cautions that individual anatomy varies too much for it to be used as the only training tool to learn mechanical thrombectomy, but says that it could potentially be used to visualize other conditions, such as brain tumors. Surgery for brain tumors has significant lead time, and modeling the tumor in advance could personalize and improve patient care.

“Creating these high-level 3-D models customized for individual patients has the potential to significantly improve outcomes and reduce operative times by enhancing surgical planning,” Bulsara says.

The new epilepsy unit will feature a high-density geodesic EEG with more than 250 sensors in a cap like the one pictured. Oli Scarff/Getty Images

UConn Health is now home to a high-tech Epilepsy Monitoring Unit.

Located on the first floor of the new tower at UConn John Dempsey Hospital, the unit has two large patient rooms with state-of-the-art technology; 24-hour video observation capabilities; the latest in advanced electroencephalography (EEG) monitoring; and a dedicated team of neurology and neurosurgery doctors, nurses, and staff.

If needed, patients can be monitored for up to several days so doctors can determine whether the seizures are caused by epilepsy, what kind of seizures they are, and where they originate, says Dr. L. John Greenfield, chair of the Department of Neurology at UConn Health and a nationally-recognized epilepsy specialist. The monitoring information is critical to figuring out the best way to halt the seizures.

For patients with epileptic seizures, the information gathered helps doctors create a personalized clinical care plan and choose the most appropriate medications or adjustments for the patient’s seizure type.

For patients who may need surgical intervention to control their seizures, the new unit will allow doctors to precisely localize where the seizures start in the brain to see if neurosurgery might be a beneficial treatment option. According to Greenfield, if the seizure starts in the temporal lobe, there is a 70 to 80 percent chance the seizures can be cured with brain surgery.

Greenfield hopes the data and insights gained from the new unit’s video and EEG monitoring will advance future brain research and clinical care for epilepsy patients. The new unit will soon offer high-density geodesic EEG recordings that can sample patient brain wave data using more than 250 electrode sensors contained in a wearable, stretchy web that fits over the head like a swim cap. This device can pinpoint epileptic activity with much higher precision than traditional EEGs, which record signals using only 19 electrodes.

“With the combination of our state-of-the-art monitoring unit, clinical care, research, and our new chief of neurosurgery, Dr. Ketan Bulsara, UConn Health can now provide comprehensive care for patients with epilepsy and with seizures due to brain tumors or vascular malformations,” saya Greenfield. Bulsara specializes in skull base, endovascular, and tumor neurosurgery.

Dr. Ketan R. Bulsara, a world-renowned neurosurgeon, brings an unparalleled range of expertise in treating neurological disorders to UConn Health as the new chief of the Division of Neurosurgery.

Bulsara came to UConn Health from Yale, where he built successful programs in neurovascular and skull base surgery. He has trained with the pioneers in neurosurgery and is an author on many national and international guidelines
and standards.

Bulsara is among an elite few neurosurgeons in the world with dedicated dual fellowship training in skull base/cerebrovascular microsurgery and endovascular surgery. He is directing both of those disciplines in UConn Health’s Department of Surgery in addition to serving as chief of neurosurgery.

“Dr. Bulsara is a world-class neurosurgeon who brings a level of expertise that is almost unheard of in the field,” says Dr. David McFadden, chair of the UConn Health Department of Surgery. “Whether it’s complex tumors, aneurysms, or any sort of brain- or nerve-related problem, he is well-equipped to offer a full range of treatment options.”

That includes the full spectrum of treatment of both hemorrhagic stroke and ischemic stroke. Bulsara was an early adopter of mechanical thrombectomy, a procedure in which the surgeon removes a clot from a blocked blood vessel going to the brain. Bulsara’s collaboration with UConn Health’s stroke program puts UConn Health in a position to handle these more complex cranial cases.

Bulsara also will be involved in UConn Health’s efforts to expand its epilepsy program to include neurosurgical treatments, and will be recruiting additional neurosurgeons with other areas of expertise.

“It’s always been my dream to establish a world-class destination center for neurosurgical care,” Bulsara says. “Neurosurgery, the way I look at it, is a multidisciplinary specialty. The focus of my division is to optimize patient outcome. We’ll build a team that’s tailored and personalized for every single patient. Ultimately, as a team, we provide the best care for the patients.”

Dr. Ketan R. Bulsara

Education:

Davidson College, B.S.

Duke University, M.D.

Residency:

Duke University Medical Center, Neurosurgery

Selected Accolades:

America’s Top Surgeons, Consumer Research Group of America (2007, 2009, 2010, 2011, 2012)

From the American Association of Neurological Surgeons and the Congress of Neurological Surgeons:

For 30 years, Frank Ditaranto worked in the construction field. But a sudden back injury changed that, leaving Ditaranto unable to carry on his normal life.

“Two years ago, my back went out and it stayed that way,” says Ditaranto, a 50-year-old Terryville, Conn. resident. “Ever since, I have been bent over like I was 90, with shooting pain down my left leg to my toes, and I was unable to even straighten my leg.”

Daily life and even walking became difficult for Ditaranto. He tried pain medicine, physical therapy, aqua therapy, and epidurals, but there was no relief in sight — until now.

On Jan. 7, Dr. Isaac Moss, assistant professor of orthopaedic surgery and neurosurgery at the Comprehensive Spine Center at the UConn Musculoskeletal Institute, was the first surgeon in New England to use the new Mazor Robotics Renaissance Guidance System to assist him during spine surgery. Ditaranto was his first patient.

“Thanks to the robotic technology, we were able to place screws in the patient’s spine with extremely high accuracy, small incisions, and minimal intraoperative radiation,” says Moss.

UConn Health is the first institution in New England to offer patients this pioneering and more precise robotic guided spine surgery.

A day after the surgery, Ditaranto said he already felt truly transformed: “For the first time I was able to stand up straight and not have pain shooting down my left leg.”

“I am too young to have to live like that,” says Ditaranto. “I now have new discs and hardware in my spine and I am good to go.”

Ditaranto says he feels “great” and looks forward to simply living life pain-free. Perhaps most importantly, as a single dad of a 16-year-old daughter, he most anticipates playing volleyball with her again.

Most spinal procedures like Ditaranto’s involve the attachment of screws and other implants to the spine. Spine surgery has little room for error. Spinal fixations, such as screws, are typically just millimeters away from sensitive spinal nerves, the spinal cord, the aorta, and other critical vessels.

The new technology’s software allows surgeons to plan a patient’s spine surgery virtually, using a 3-D simulation of the spinal anatomy based upon the patient’s most recent CT scan.

“It’s so important to plan in advance of spine surgery,” says Moss. “The Mazor Renaissance technology allows a surgeon to closely review the anatomy of each patient in depth, and get to know the specifics, to make a more precise surgical plan, and eventually execute a smoother operation.”

Once inside the operating room, the Mazor technology matches, in real time, the surgeon’s pre-operative 3-D plan with intra-operative X-ray imaging of the patient’s spine. During the procedure, the technology guides its robotic arm, which is about the size of a soda can, along the spine to help the surgeon pinpoint the precise location to place his tools to ensure the greatest accuracy and safe placement of screws and other hardware into the spine.

UConn Health is using the robotic-guidance technology for a wide range of spinal procedures including biopsies, thoracic and lumbar spinal fusion, and reconstruction for a wide variety of conditions such as scoliosis (abnormal curves in the spinal column), spondylolisthesis (when one vertebra slips forward onto the vertebra below it), tumors, and trauma, among others.

“Using this advanced technology puts UConn Health at the forefront of spinal surgery,” Moss says. “This technology allows us to perform both traditional and minimally invasive spine surgeries more effectively and safely.”

Other potential benefits of the robotic guidance technology include smaller incisions, shorter operative times, shorter hospitalization and recovery, less pain for patients, and less exposure to fluoroscopy X-ray radiation for both a patient and the surgical team.

Research shows that compared to freehand spine surgery, the robotic guidance technology can increase the accuracy of screws and other hardware placement by 1.5 mm. This increased accuracy may also reduce the potential for neurologic risks to patients, which may include future nerve pain, tingling, or tissue numbness.

Two other UConn Health surgeons in addition to Moss — Dr. Hilary Onyiuke, director of the Comprehensive Spine Center at the UConn Musculoskeletal Institute and chief of the Division of Neurosurgery, and Dr. Ryan Zengou, assistant professor in the Department of Surgery’s Division of Neurosurgery and the Department of Orthopaedic Surgery — plan to use the system.

“I look forward to using this technology to help patients with spinal pathology by performing complex procedures with optimal precision and the best outcomes possible,” Moss says.